A 53-year-old caucasian male with a history of alcohol and amphetamine abuse presents to the Emergency Department via ambulance immediately after sustaining a fist-blow injury to the right eye. The patient denies loss of consciousness and complains of eye pain with the inability to see.
Vitals: T 36.9°C; BP 181/119; HR 110
General: Alert and oriented; anxious; agitated
Ophthalmic:
OD:
- Visual acuity – no light perception
- Pupil 4mm, irregular shape, and fixed
- Extraocular movement – none
- Proptotic; Conjunctival prolapse; Subconjunctival hemorrhage
- Anterior chamber hyphema
- IOP 55 mmHg
OS:
- Visual acuity – 20/20
- Pupil 3mm round and reactive
- Extraocular movement – intact
- IOP 12 mmHg
Non-contributory
A lateral canthotomy and cantholysis.
This procedure is easily performed at the bedside in the ED and the transected lateral canthal tendon and inferior/superior crus can be repaired during the repair of the presenting injury. Patients report improvements in pain and sometimes vision in as little as 10 minutes after the procedure.
A CT should be ordered after performing a lateral canthotomy and cantholysis to minimize the complications associated with elevated retrobulbar pressure including ischemia and permanent loss of vision. This photograph depicts a patient who presented to the ED suffering from the effects of orbital compartment syndrome (OCS) after being punched in the eye. OCS can develop from as little as 7mL of fluid accumulation in the retro-orbital space and can rapidly lead to permanent blindness if ischemia is present for more than 100 minutes. Symptoms of OCS requiring immediate lateral canthotomy and cantholysis include: proptosis, increased intraocular pressure, Marcus-Gunn pupil, decreased acuity, or restricted ocular movements. Importantly, OCS is a clinical diagnosis, and treatment of this condition should not be delayed for further testing or diagnostic workup. While treatment may not result in the return of vision, there are many case reports of patients regaining full or partial vision up to two hours after the onset of symptoms.
Take-Home Points
- Don’t delay! Quick action can save your patient’s vision.
- Signs of OCS requiring immediate bedside surgical intervention include:
- Proptosis
- Increased intraocular pressure
- Marcus-Gunn pupil
- Decreased visual acuity
- Restricted ocular movements
- Rowh AD, Ufberg JW, Chan TC, Vilke GM, Harrigan RA. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med. 2015 Mar;48(3):325-30. doi: 10.1016/j.jemermed.2014.11.002. Epub 2014 Dec 16. PMID: 25524455.
- Jaksha AF,Justin GA, Davies BW, Ryan DS, Weichel ED, Colyer MH. Lateral Canthotomy and Cantholysis in Operations Iraqi Freedom and Enduring Freedom: 2001-2011. Ophthalmic Plast Reconstr Surg. 2019 Jan/Feb;35(1):62-66. doi: 10.1097/IOP.0000000000001168. PMID: 29979268.
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